Future Health Care in Ageing Societies
Ton Venhoeven, 2012
VenhoevenCS contributes to high-quality, affordable health care through efficient organisation and by designing a healthy and attractive urban environment. Healthy communities and cities, prevention, and active ageing are interconnected and important areas of focus with the potential for significant profit. One of the examples of the innovative concepts we have developed is the “Core Hospital”. In 2004 this concept/design won the international competition “Future Hospitals, competitive and healing”.
Ton Venhoeven is a member of the advisory board of the Dutch Centre for Health Assets and a member of the advisory board of Architecture in Health. VenhoevenCS works in close collaboration with an international network of top specialists in hospital design. Ton Venhoeven and Bas Römgens are frequent lecturers on health care design and city planning for an international audience.
Future Health Care
The combination of major cost increases in recent years, an ageing population and technological advancements will bring dramatic changes to the healthcare sector in the coming years. With the technology available, the care itself can be organised much more efficiently in network relationships than in the current regional organisation. This can save a lot of money and reduce the number of personnel required. This trend will also have a major spatial impact, in that it will render many healthcare buildings unnecessary.
"care can be organised much more efficiently in network relationships than in the current regional organisation"
Sharp increases in healthcare costs are being seen in virtually every country in the world. In the Netherlands, for example, these costs rose between 1994 and 2008 from 11.2% to 14.8% of the GDP. Ongoing technological advancements make this care more and more available, and demand for it is steadily increasing. But there are also cultural and demographic causes. As many areas dwindle demographically, for the remaining residents the hospital is often the last facility that offers human contact, and so they are maintained in these areas at high cost. Care costs are also being driven up by factors such as the increasing demand for elective surgery, pregnancies at higher ages, and, perhaps most predominantly, an increasingly ageing and obese population.
In the Netherlands, the number of people aged 65 and up is set to double in the coming fifteen years (from 15% to 30% of the population), due to a rising life expectancy and falling birth rates. But this percentage differs dramatically from region to region: in the big cities, it is 15%, while in demographically shrinking areas it is 65%. Although senior citizens are more active and physically fit today than they were a few decades ago, a disproportionate amount of healthcare costs still goes towards this last phase of life. That means more demand for care, fewer available personnel to give it (particularly in demographically shrinking areas) and reduced tax revenues. Here, the Netherlands represents a frequently encountered average; Japan and Italy will be ageing 1.5 times as fast by 2025, while countries in Africa are ageing much slower.
Sources: PBL (2011), United Nations (2007)
"care costs are being driven up by factors such as an increasingly ageing and obese population"
The potential of E-health, ambulance and helicopter
The risks of further increases in healthcare costs are many, but there are also many new technological developments to help organise healthcare much more efficiently. Chronic patients have long had the opportunity to use a smart phone app to run their own checkups rather than visiting the hospital for every checkup. These days, diagnosis and even some surgical procedures can be done remotely. Modern ambulances and helicopters are so advanced that they have become mobile operating rooms in which patients can be stabilised en route, so patients can be transported a much greater distance to the hospital. This makes many hospitals redundant. In addition, many types of medical equipment have become much smaller and much more affordable, so that today even small community clinics can perform the same high-level diagnostics that were once reserved to state-of-the-art hospitals.
New structure of healthcare
In the Netherlands, the National Healthcare Council has recommended a new strategy for reining in the sharp increase in costs of care and preventing the impending shortage of personnel in the sector. A care network of local community clinics, compact core hospitals for acute and scheduled treatments, high-tech ambulances and helicopters, Internet services, care hotels, specialised clinics, centralised labs and scientifically equipped medical centres for complex cases creates a much more efficient infrastructure of facilities and connections.When these plans are implemented, it is the general hospitals and community health care facilities that will see the biggest changes.
"The general hospital becomes core hospital"
The move in the future will be towards a great de-centralisation of the cure, which will allow hospitals to be organised much more efficiently than they are now. Today, many hospital beds are frequently empty, because the average bed time required per person has been halving every ten years for decades now. Even despite a sharp increase in the number of treatments, the total number of bed days in the Netherlands has been cut by 50% in the past 25 years. Many outpatient clinics are only used for part of the day; labs can be much more efficiently set up outside of the actual core hospital, as can the kitchens, the administration, the immunisation and injection clinic, the laundry, the florist and the hairstylist.
Even the core hospital itself can be significantly trimmed down; estimates indicate that it can operate as well with half of its current space. That space must be set up as flexibly as possible, with a high storey height, because the working processes are in a constant state of change with the advancements in medical technology. In addition, it makes sense to put the building in a good place in the city, so that the decentralised facilities can, if possible, be located in the neighbourhood, and where they can also serve clients other than just patients. The low threshold hospital also attracts passers-by with vague symptoms, and can profit from other facilities in the area such as high-frequency public transportation and good hotels and offices.
In a network with other service providers, each can concentrate on their own core business, the things that each organisation is best at. This all creates an extremely flexible and innovative organisation of care, and the patient is better off as well, because at present many hospitals perform certain complex treatments too occasionally to develop a routine in them and to deliver true quality.
First-line care replaced by community clinics
The community clinics of tomorrow will take over some of the tasks of the hospital and all of the tasks of a general practitioner. This will make it possible to treat people much closer to home with high-quality, low-threshold care; establish better diagnoses at an earlier stage; and take over minor procedures currently performed in hospital. Cooperation with home care, sports, cultural and educational institutions will create a strong infrastructure in which early diagnosis can be combined with prevention at the community level. The school, for example, can play a role in identifying learning problems and other developmental deficiencies that may be an indicator of illness, drug use, bulimia, family problems or chronic inactivity.
Integration of healthcare in the city
These facilities can also be directly engaged to promote a healthy lifestyle. Taking part in sports can be an important part of improving mental and physical health, as well as training social skills. Participating in education promotes self-reliance, and cultural centres offer a place to meet and interact with other people. An attractive public space with good public transportation helps to achieve all these ends, and invites people to go out, to walk, to cycle, to play, to walk the dog and to meet friends. The healthy cities that can emerge in this way are the best prevention for a range of health problems. This infrastructure is also what makes decentralisation of the care feasible, and what allows the elderly and people with chronic conditions or handicaps to live independently for as long as possible, with the assistance of customised care. This fits in perfectly with what the World Health Organization expresses in its Healthy Cities Network initiative: the self-healing capacity of cities, within which it is not only the hospital with a part to play in making and keeping people healthy, but the entire city serving the goal of health. In the end, healthcare does not start in the hospital or clinic, but in the social embedding of health care, prevention and the promotion of healthy lifestyles.
"healthy cities are the best prevention for a range of health problems"
Of course, there are also those conditions that unavoidably necessitate prolonged hospital stays. Here, it is good to keep in mind that buildings, too, can have a healing effect. Various research in the areas of the Healing Environment and Evidence-based Architecture is gradually revealing the scope and complexity of the relationship between building and healing. This also means that the existing conceptions of the architecture of care institutions is changing. The architecture of the hospital can activate and stimulate patients to heal themselves. This is important, because today’s care client is an active patient who works on his or her own healing, in contrast to the sedentary, bedridden patient of yesterday who was only a passive recipient of care. A good building can help by training the body, ears, eyes and brain in a variety of ways to get people active and vital earlier, faster or longer. An unusual staircase, for example, in a prominent place in a building, can encourage people to take the stairs instead of the lift. And natural light in an operation room can improve the surgeon’s concentration. And an inner courtyard can give patients a place to experience nature up close, which can reduce stress and accelerate healing. 1
Changes in duration of care
First and foremost, this means that the position of the patient is changing. A hospital or care institution far removed from everyday society makes a person being treated there “institutionalised,” someone who is passively undergoing a treatment. This generates hospitalisation effects, leaving the care client sedated and institutionalised, and as a result not adequately stimulated to actively work towards his or her own recovery. Another effect that arises in a clinical environment is that the desire for care increases the more care that is provided. Patients coming for day treatments or outpatient treatment particularly benefit from not being treated as a patient, but as a customer coming to “pick up” a treatment.